Training of rural healthcare providers Note: This summary will be updated regularly as new content emerges from HIFA2015 discussions.

Transcription

1 HIFA2015 Summary 2 January 2007 Training of rural healthcare providers Note: This summary will be updated regularly as new content emerges from HIFA2015 discussions. This is a combined summary of two related threads: 1. Reforms in medical education to increase informed providers at the frontlines (13 messages; 5-8 January 2007) and 2. Training of rural healthcare providers (25 messages; 7 January March 2007). 38 contributions on this subject were received by 25 members from 8 countries (Australia, Eritrea, Fiji, India, Malaysia, Trinidad, UK, USA). A list of contributors, with their profiles, is appended below. The discussion started on 5th January 2007 with a message from Meenakshi Gautham, India. She said: Most of us who live and work in low resource settings realise that the conventional medical profession is quite out of sync with national level public health needs. Skilled and good quality medical care is out of reach of rural and urban poor populations - those who bear the greatest burden of mortality disease, while the medical profession is driven mainly by standards of academic excellence that are typically met by students from privileged educational backgrounds. In India, about 80-90% of qualified medical professionals work in the private sector and are concentrated in well-to-do urban areas. Some of us in India have been arguing for reforms in medical education on two fronts: One, to increase the rural and social orientation in the current medical undergradute courses and to focus on developing skills that meet the reality of the primary health care setting, and Two, to develop shorter 2-3 year medical courses to develop a cadre of basic health care providers, who would be recruited from rural areas and would be able to live and work in the communities they come from... The greatest obstacle to these short courses would be the hegemony of the medical elite over modern medicine and its practice. I think that HIFA may have to play a significant role in countering this hegemony which makes it illegal for anyone who does not have a full medical degree to practice modern medicine. WHAT KIND OF TRAINING IS NEEDED FOR VILLAGE HEALTH CARE? A member pointed us to an article by CM Christensen, R Bohmer, J Kenagy - Harvard Business Review, 2000, Will disruptive innovations cure health care?, in which it is said: "It's no secret that health care delivery is convoluted, expensive, and often deeply dissatisfying to consumers....nurse practitioners, general practitioners, and even patients can do things in less-expensive, decentralized settings that could once be performed only by expensive specialists in centralized, inconvenient locations. But established institutions-- teaching hospitals, medical schools, insurance companies, and managed care facilities--are

2 fighting these innovations tooth and nail. The aim of the article was to promote how simple, affordable medical innovations can help revitalize U.S. health care. But the message is perhaps applicable worldwide. A member alerted us to a piece by the economist Jeffrey Sachs in Foreign Affairs, Jan/Feb 2007 ( More doctors and nurses need to be trained, and urgently. Just as important, however, will be new cadres of village health workers who should be trained for a few months each in order to help handle a host of basic health challenges within the village context (malaria control, diarrhea control, family planning, etc.). A member suggested the training for this new workforce should have more emphasis on enabling health workers to help local communities develop their knowledge about the relationship between social circumstances, develop skills and strategies that will help them to make real changes in their lives. A member emphasised the importance of health workers being culturally sensitive in approaching patients and their families. Reflecting on experience of Asian communities in the UK, she said: There is a common mis-conception that people who are not literate in the English language are not knowledgeable about health-related issues. This assumption is wrong. People who cannot read or write in English usually have other highly developed life skills for communication and acquiring knowledge. Also, regarding community outreach workers: (a) a person's health is 'private business' and the outreach worker can be seen as 'invading one's privacy' (b) outreach workers are usually young and educated in the west. A person young enough to be one's grandchild does not have the same weight as the knowledge and insight gained after a life-time of experience no matter how enthusiastic the outreach worker is. A further comment from Meenakshi raised a broader question about expert approaches to meeting the needs of poor people generally: I have reservations about the epistemological approach that appears to govern the global health community's understanding and/or articulation of the lack of options, decision making etc faced by the world's poor... to summarise, I think the problem really lies with how far 'we' are willing to perceive, understand, confront and deal with 'their' problems, knowing that doing so might create problems for 'us'!! Two members expressed disagreement with the creation of a lower tier doctor : I can understand the concerns of Dr. Gautham but creating a lower tier doctor is not, I believe the answer...the practice of medicine, particularly at the community level, should be a team effort, directed by physicians. And: Let us not return to the feltcher or the shoeless practitioner or medicine practiced by a pharmacist aid or a nurses aid... If there are enough MDs let them practice at all levels but if not he shall delegate to other members of the team but under his direction. A member suggested there was nothing new about this proposed new cadre of health worker: the use of village health or community health workers has been in practice for years in many parts of the world and particularly in Africa, many more are needed. Another member asked: Who will be providing health care in 20015? The health care of the majority of the urban and rural poor will predominantly depend on nurses and medical assistants. A member sounded a word of caution. In Fiji, lower rungs of medical practitioners were removed without realizing the impact that it was going to create. Hence we were left with doctors who serve only in disease palaces.

3 Meenakshi asked for help and advice from members on Curriculum development: From those of you who have been working on community level curricula, please could you share your experiences, useful guidelines and material and also the options for certification of such a course. A member from Eritrea shared an outline curriculum for 2 month training of Community Health Workers. He recommended that trainee candidates should be selected by communities but final selection by entrance test to assess literacy. It is important to get the village administrators to attend the graduation ceremony to let them now that you have done your share and communities have to take their responsibility in managing the community health care delivery. Remuneration of CHWs is the responsibility of the beneficiary community, he said, but the supporting organisation can provide funds to purchase essential drugs and furniture. Regular supportive supervision should be done by the nearest health facility staff at least every 2-3 months. HOW CAN WE MEET THE INFORMATION NEEDS OF RURAL HEALTH WORKERS? Feedback to a small TALC survey from nurse and medical assistant training schools suggests they have less than five [total] of any textbooks, suitable for nurse of medical assistant students to study from, for perhaps an intake of 40. If students are not used to studying from books they are less likely to use them when trained. The books available we find are often written for students in Europe or N. America, are expensive and not appropriate in content and level of English. Teaching-Aids at Low Cost (TALC) have identified low cost texts written specifically for workers in less privileged countries. For further information: Appropriate books need appropriate evidence, of which we have relatively little as compared with high-tech medicine: Could we say that the whole evidence based edifice is a western effort and seriously biased towards topics and approaches for which trials are done? We know the trials that are done are the trials that get paid for and it is not surprising therefore that there is a very significant bias towards treatment in ebm studies. This is fine for New York but many poor income countries cannot begin to pay for the drugs gold standards require. Clinical Guidelines in Gastroenterology... are OK for New York or London but pretty useless in most parts of the world.... How can we make health information (never mind who delivers it - and barefoot or not - and how they have been educated/trained) relevant to those using it?... And the large STM publishers? Well, they publish in areas where the money is eg Hepatitis B and C - not A and E... We need a kind of Cochrane Collaboration but then one which deals with creating evidence based solutions for low and medium resourced countries focussing on tools and technologies of use in areas where they will be used. Another member pointed out the despair that information can bring to patients if they are powerless to benefit from it: In the outpatient departments in Nepal and India after listening to my patients I sensed their despair particularly as they knew (someone had told them or the media had projected) that an expensive solution is available to their problems. They knew that it was available but not to them. I felt this was one of the worst form of complication or side effect of information access to the masses that I had come across. A member described how it is often difficult to walk the line between the promotion of "western" evidence-based practice and respect for local knowledge of how people learn and make the important choices that impact their personal health. This would be a key element of the next Pacific Global Health Conference to be held in Honolulu in June 2007.

4 Smartphones and PDAs could be used to empower these community health workers, said one member. The success of this approach has been demonstrated in Uganda and South Africa... book publishers are no longer open to making low-cost medical textbooks but rather interested in ICT and internet. So reason might be to work with them to develop contents and materials on cheap and accessible ICTs such as mobile technologies. A member suggested an alternative approach to the challenge at hand - personalised health informatics - and this gave rise to a new thread (See Summary: Personalised health informatics and ICT-enabled health coaches, on Resources section of A member reminded us that information in itself is not enough: Creating infrastructure at the villages in India is very important for doctors to feel at home and feel that they are not being discriminated. Just by having books and computer aided dissemination of information is not going to help. OUTCOMES This discussion was notable because it demonstrated real practical benefits: On 7th January, we received a second message from Meenakshi: This has been a most rewarding discussion... I am seriously inspired to set up a social enterprise company that recruits, trains and manages an accredited network of rural providers who would provide not only curative but also preventive and promotive holistic health care. A number of members expressed enthusiasm about this exciting project, brilliant, novel idea. One said: I will be willing to contribute from a business perspective to your project. Two months later, on 14 March, Meenakshi wrote again to say: I'm delighted to share that I've received some very positive support for this enterprise: IIT Madras (Indian Institute of Technology) has offered to incubate the company and will support the pilot project for a duration of one year so that we can work on getting all the systems in place and explore the business model requirements... I have a draft project proposal ready that I can mail to anyone who is interested to know more... 3 cheers for HIFA2015, and for HIF-net and CHILD2015" without whom none of this would have happened! These discussions have helped me so much with the quality of my thinking and egged me on to dream big! Other members responded, asking for copies of the proposal to help carry out similar work: 1. I am interested to replicate your endeavour in the eastern part of India, particularly in West Bengal. 2. We are working with a group of students in the development of teaching/training of healthcare workers in Cambodia and Tanzania. 3. I am off to Afghanistan to work on a project involved in the training of community health workers, specifically to identify, prevent and refer on for disabilities. Despite the differences to your project, there are enough similarities for your draft proposal to make interesting reading for me. We look forward to hearing more about HIFA2015 members experience in this area. CONTRIBUTORS Rakesh Biswas is Associate professor, Department of Medicine, Melaka-Manipal Medical College, Melaka, Malaysia. He is a physician academic trying to merge two worlds, the developing and developed in his day to day practice. He has worked in India, Nepal and Malaysia. His interests include Medical problem solving, education and evidence based telemedicine.

5 rakesh7biswas AT gmail.com Tushar Dey is an epidemiologist in All India Institute of Hygiene and Public Health, Kolkata under Ministry of Health & Family Welfare, Government of India. He is interested in Public Health Informatics and its application in disease surveillance and epidemic forecasting. drtushar.dey AT gmail.com Meenakshi Gautham has a PhD in Public Health and Policy from the London School of Hygiene and Tropical Medicine, and is currently an independent public health consultant based in Delhi, India. Her special area of interest is how to better connect, better inform and better support health systems and the health workforce in rural, poor and low resource settings. Meenakshi.Gautham AT lshtm.ac.uk Stephen M Goldstein is Chief, Publications Division, The INFO Project, Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, Baltimore, USA. The INFO Project offers a range of information resources and services to ensure that information, knowledge, and best practices for family planning/reproductive health (FP/RH) are accessed by multiple audiences with different needs. sgoldste AT jhuccp.org Paul Heinzelmann works with Partners Telemedicine, a non-profit organisation based in Boston, USA, utilizing telemedicine to bring sustainable and quality health care to underserved populations. Paul is head of Partners Telemedicine s program in Cambodia, Operation Village Health, which links clinics in remote areas of Cambodia with physicians at Massachusetts General Hospital, Brigham and Women s Hospital, and Partners/Dana Farber Cancer Care. Paul is board certified in Family Medicine, received a Diploma in Tropical Medicine and Hygiene from the Royal College of Physicians, London and is an MPH candidate at the Harvard School of Public Health. He is committed to providing increased care and access to underserved populations through the use of communications technologies. PHEINZELMANN AT partners.org Adesina Iluyemi is a dentist by profession with Masters degree and postgraduate Royal College of Surgeons, England diploma in Dental Public Health. He is presently a PhD candidate at the Centre for Healthcare Modelling and Informatics, University of Portsmouth, UK studying Mobile Health Information System (Telehealth) in developing countries context and focussing on the use of mobile technologies to support community health workers. He is also interested in the use of mobile technologies for the management of chronicdisease patients especially HIV/AIDS. adeiluyemi AT yahoo.co.uk Justus Krabshuis runs the Ask a Librarian service of Highland Data, Argyll, Scotland, UK The Ask a Librarian service is a worldwide group of expert biomedical librarians and information scientists providing a remote and on-demand gastroenterology service, mainly for Africa. justus.krabshuis AT highland-data.com Jose Lacal has a BA in Economics and is pursuing a Master's in Public Health. His current area of research is centered around his concepts of Seamless Health and Personalized Health Informatics to deliver customized personal and public health services to the individual using Information and Communication Technologies (ICTs) ( Jose leads the Seamless Health Center of Excellence at Motorola, Inc. based in Plantation, Florida, USA. Jose.Lacal AT motorola.com Jorge Maldonado is a senior physician, former Full Professor of Medicine at the Mayo Clinic, from Colombia with an interest in health information. He works on Saludhoy.com and Iladiba.com and cursosiladiba.com websites, which deliver health information to health

6 professionals and the general public in alliance with Colombia's National Academy of Medicine and National Institute of Health. jorgem AT emsa.com.co Peter Mansfield is Director of Healthy Skepticism Inc, an international non-profit organisation for health professionals and everyone with an interest in improving health. The main aim of Healthy Skepticism is to improve health by reducing harm from misleading drug promotion. Peter is also a general practitioner, and Research Fellow, Discipline of General Practice, University of Adelaide, Australia. Publication list: peter.mansfield AT adelaide.edu.au Haranadh Mehar works with the Srujana Welfare Association, a non-governmental organisation in Visakhapatnam, Andhra Pradesh, India. Srujana works to reduce child and maternal mortality. srujanangoindia AT rediffmail.com David Morley is President of Teaching-aids At Low Cost, a UK-based non-governmental organisation. He is also Professor Emeritus at the Institute of Child Health, London. He is involved in selecting material for TALC to distribute, and resources for inclusion on TALC free CD-ROMs. david AT morleydc.demon.co.uk Vincent O'Brien is a Senior Lecturer in Public Health, Faculty of Health and Social Care, St Martin's College, Lancaster, UK. vincentobrien AT mac.com Ayo Onatola is the Librarian at St. Christopher Iba Mar Diop College of Medicine, Luton, England. He holds BSc (Hons) Biochemistry, PGDE, MLS [Ibadan]. He is the former Librarian, Medical Schools/ Teaching Hospitals of Ogun State (now Olabisi Onabanjo) University, Sagamu ( ) and Lagos State University, Ikeja ( ), Nigeria. Author of the book "Basics of Librarianship - theory & practice: a guide for beginners", published His professional interests are in ensuring access to updated Biomedical and Clinical Information in support of excellent medical education, cutting edge research and delivery of effective patient care. He is professionally affiliated to Association for Health Information & Libraries in Africa (AHILA), Nigerian Library Association (NLA); Chartered Institute of Library & Information Professionals (CILIP), UK; and Biohealthmatics Africa Network (BHAN). He currently serves on the Advisory Panel of HIFA2015 Campaign. ayoonatola AT yahoo.com Anjana Patel is a pharmaceutical scientist and a writer based in the UK. She has an MSc in pharmacology and a PhD in medicinal chemistry and is a published author of a book on Diabetes Mellitus for pharmacists. Her main interests are: 1. Provision of good quality and validated information about health care interventions for front line healthcare professionals. 2. Systematic assessment of harms of medical interventions. 3. The role of traditional herbal medicines in an allopathic medical system. Anjana s working experience includes working as a clinical editor for BMJ Clinical Evidence (an evidence based resource of information about health care interventions) and as an assistant editor for the British National Formulary (a national resource of drug prescribing information for drugs available in the UK). She has also worked both as a hospital and community pharmacist in the UK. anjanan.patel AT virgin.net Solomone Qaranivalu is a health informatics professional at the Ministry of Health, Fiji. sqaranivalu001 AT health.gov.fj James Rarick is Partnership Program Coordinator of the Cancer Information Service Pacific Region, a program of the National Cancer Institute serving Hawaii and the U.S. Territories in the Pacific. He is based at the UH Cancer Research Center of Hawaii, in Honolulu. JRarick AT crch.hawaii.edu

7 Sonia Roache-Barker is a Family Practitioner working in Trinidad, West Indies. She is a Founding Member of the Caribbean College of Family Physicians and also a member of WONCA (World Association of Family Doctors). She has varied interests but particularly in furthering compulsory CME and CPD in the Caribbean islands. She also works in Occupational Health & Safety and Sports Medicine, and is an Associate Lecturer in Family Medicine at the University of the West Indies. Svrccfp AT yahoo.com Toumzghi Sengal is a program manager in health and nutrition with Vision Eritrea, Asmara, Eritrea. Vision Eritrea is a national NGO that strengthens community based health care delivery system with the training of community health workers in C-IMCI (Community Integrated Management of Childhood Illness). Toumzghi trained in Northeastern University Boston and had been practising in USA. sengal AT gemel.com.er Vinit Shah is a paediatrician with the East Kent Hospitals NHS Trust, UK. vinit.shah AT ekht.nhs.uk Rachel Stancliffe has a background in demography and public health. She is a co-director of the Global Healthcare Information Network ( Rachel has extensive experience in development work in many countries, including Georgia, Kazakhstan, India and Latin America. She works at Update Software Ltd, a publishing and software company based in Oxford, UK, which specialises in assembling, preparing and disseminating information needed to make informed health care decisions. rstancliffe AT update.co.uk Paget Stanfield is a retired paediatrician with an interest in the availability of learning materials and textbooks for medical students and postgraduates in developing countries. He has a long experience in Africa, particularly with the Makerere University, Uganda, and AMREF. Paget is editor of the textbook, Diseases of Children in the Tropics. welcome.stanfield AT c-pac.net Joanne Thomas has a special interest in rehabilitation and specifically access / appropriateness of physiotherapy services in developing countries. She qualified as a physiotherapist in 1990 from Sydney University. Over the last 3 years she has travelled to East and West Africa. She is presently undertaking a Masters in International Public Health (University of Sydney) and seeking an appropriate existing project in a developing country with which she can contribute research of a practical purpose. thomasj65 AT hotmail.com Lalji K Verma is a retired Air Marshal of the Indian Air Force, having retired from the position of Director General of Medical Services. His expertise is in the field of healthcare waste management, and solid waste management. He is current President of Indian Society of Hospital Waste Management (ISHWM), and President of VIKALP - Seeking Waste Solutions through Alternatives. vermalk AT bol.net.in or laljeeverma AT vsnl.net James M Walker is Chief Medical Information Officer, Geisinger Health System, Danville, PA, USA. He is an internationally recognized lecturer, consultant, and thought leader in the fields of electronic healthcare record (EHR) development and usability. He leads Geisinger's development of integrated outpatient, inpatient, and patient EHRs. He practices internal medicine and has published numerous journal articles and a widely used book, Implementing an Electronic Health Record System, in the Health Informatics Series (Springer-Verlag, 2005). Dr. Walker is a fellow of the American College of Physicians. He serves on the Biomedical Library and Informatics Review Committee of the National Library of Medicine; the Medical Informatics Sub-Committee of the American College of Physicians; the Ambulatory Functionality Work Group, Certification Commission for Health Information Technology (CCHIT); and the board of the Pennsylvania ehealth Initiative. He has provided briefings to the National Health Policy Forum, the National Committee on Vital and Health Statistics, MedPAC, and Pennsylvania House and Senate committees. Walker received his

8 MD degree from the University of Pennsylvania before training in internal medicine at Penn State University. He completed a National Library of Medicine fellowship in medical informatics. jmwalker AT geisinger.edu Summary prepared by Neil Pakenham-Walsh, HIFA2015 moderator, 11 April 2007 Join HIFA2015 and CHILD2015 forums - send your name, organisation and brief description of your professional interests to hifa2015-admin@dgroups.org and child2015-admin@dgroups.org